=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881349611
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLNATH MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2022
-----------------------------------------------------
Last Update Date | 03/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26809 TANIC DR STE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-435-5199
-----------------------------------------------------
Fax | 813-796-5389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26809 TANIC DR STE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-435-5199
-----------------------------------------------------
Fax | 813-796-5389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LISA NYANDA-MANALO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 813-435-5199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------